Transition Post Hospital Discharge
Transition Post Hospital Discharge
Independent Clinic Experience
Who is Multicare
 Privately owned
 Primary Care Focused
 Fridley, Blaine, Roseville
 13 FP, 3 Peds, 4 OB, 2 IM, OH, Endo, Cards
 12 PA’s, Peds NP, OB NP, FP/Wt loss NP
Agenda
 Introductions
 Independent clinic challenges in post hospital care
 High Risk patients
 COPD
 LTC
 Focused care management
 Future/ongoing plans
Introductions
 Meg Pluth, RN, MPA Director Clinic Operations, Medical Home Project Manager
 Nicole Lyden, HCC
 Kari Coddington, HCC
 Stacey Allen, HCC
 Rachel Burda HCC
Hospital Discharge List
• Purpose
• Who is called
• Numbers
• Miscellaneous
Readmission Committee
Invited to the readmission committee
meetings at Unity hospital
Discuss ways to work together to prevent
hospital readmissions
High Risk Admission Follow up
 Started with high risk medical home
 Now all high risk
 Recent addition to moderate and medium risk, all
patients
 Goal is to capture more patients for follow up/reduce
readmission
COPD
 Meeting with since 2013
 Meet every 2 weeks
 Home visits/AVS/discharge summary
 Paramedic visits
 Lung power program
 Added PA and PharmD to represent MCA
 3 day education plan, pilot
 Multicare introducing COPD education plan
Community Partnership
 Nystrom and Associates
 Phone number direct for provider to provider
 Phone number for referrals outside of regular pathway
 Geriatric Services of Minnesota
Geriatric Services Minnesota
 Relationship between GSM and TCU’s
 GSM and Heartland home
 Care upon discharge
 Struggle with communication
Home Care
 Heartland home care relationship
 Providers not completing face to face sheets
 Cheat sheet to help providers
 2 month pilot/providers
 Plans for template development in EMR
 2015 new Medicare guidelines
 HCC invite to quarterly meetings
Changes : Community Partners
 Invited to Unity Readmission Committee Meetings
 Invited to patient care conference at Unity Hospital
 Invited to care conferences Nursing Home
 Meet with all new home care agencies
 New hospice director sit down
 HCC on Heartland advisory board
 Online list of community resources tab
Focused Management
 Pain Management
 Depression patients
 Medication Therapy Management
Focus Pain Management
 Committee, 3 physicians, 2 PA’s
 Contract developed
 Policy developed
 Post Discharge , pain discussion
Depression focus
 Hospital patients discharge
 Survey to providers
 Flow chart
Provider Survey on Depression
 If a representative from Nystrom and Associates came to
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speak as a “refresher”. What questions would you have for
them/what information would you like them to cover?
When to refer vs. trial of many different medications.
What are considered 1st and 2nd line of therapies (when to
increase dose, or when to change)
How to improve resistant depression (no improvement
after multiple meds)
Medication combination therapy
Bipolar, insomnia, ADHD
Survey cont.
 The healthcare coaches recently put together a survey for the providers regarding how we
can help them better manage their depression patients. We had a total of 16 providers
return the survey. The results were as follows:
 Do you feel comfortable managing depression?
Yes -12
“Kind of”- 4
 Do you feel comfortable managing 2 or more depression medications at a time?
Yes- 6
Sometimes- 7
No- 3
 Do you feel comfortable managing a patient that is being referred to psychiatry for a
minimum of 3 months until they can get in for their psychiatry appointment?
Yes-8
Depends- 3
No-5
Survey Cont.
 We learned from the survey that many providers are
okay with managing their patients, but sometimes
need some guidance in doing so.
 Direct phone number for providers to use for
guidance.
 Work flow for focused depression patient.
Flow Chart for Depression Patients
New depression
patient
New depression
patient
Referring to
psychiatry
Yes
No, medication only
Send task to HCC to
refer to focused medical
home.
Yes
Phone message to
provider
F/u call 2
weeks after
appt to see if pt
has side effects
No
Schedule f/u appt for 24 weeks from f/u call
while patient is on the
phone
Follow up every (1) month
with provider/ follow up call
every 2 weeks after appt.
with HCC until patient is
able to get into psychiatry.
Send task to tickle file
for follow up call.
Yes
F/u call 2
weeks after
appt to see if pt
has side effects
Phone message
to provider
No
Schedule f/u appt for 24 weeks from f/u call
while patient is on the
phone
Pt seen every 3 months until
PHQ9 is stable (9 or
below). IF patient fails 2
meds send a task to HCC to
refer to focused medical
home.
Medication Management
In the beginning:
• Was a service we provided for our Medical Home patients
that were discharged from the hospital
• Med lists did not match
• A third of hospital admissions are due to medication
mismanagement
 Was a successful service!
 Reduced number of admissions
• We made it a clinic wide service offered to all patients who
take 5 or more medications daily.
Medication Management (cont.)
 Not as many patients signed up for MTM
 Message for Medication Management was put on
Patient Plans and given to patients during clinic visit
to encourage scheduling with the pharmacist.
 Pharmacist’s schedules soon became busy!
 Now is a success and we are getting good feedback
from patients and providers
Patient Advisory Committee
 Patient Advisory committee: 1 physician, 1 PA, quality
director, clinical supervisor, 5 patients (3 new this
year)
 Meet monthly
 Very engaged patient group
 Patients have input into agenda
Patient Advisory Committee
Things we have done:
 Patient portal
 Advise on new patient intake form/patient forms
 Review new reminder program
 Colonoscopy process
 HCC survey
 Provided recommendations our phone options for
incoming calls
 Provided input into recall letters
Patient Advisory Outcomes
 Turn disgruntled patient into patient advocate
 New intake forms increased self referrals to
Medication Therapy Management (MTM) program
Future plans
 Relationship with Nystrom
 Pain management enroll in Medical Home
 Better tracking ER visits
 Growing our community partners
 Reduce health care costs, i.e. reviewing health plan
usage data